Care Manager

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Identify and connect high-risk members to appropriate resources and programs to achieve optimal quality and financial outcomes • Manage and triage member self-referrals to care management programs • Identify high-risk members through HRA, reporting, and admissions data • Audit patient charts and member records for delegated case management programs using NCQA standards • Connect members with in-network providers, medical benefits, and community resources • Participate in care management program build, implementation, oversight, and delegation • Perform utilization management reviews according to established criteria, clinical guidelines, and policies • Identify barriers affecting members' quality of life • Evaluate HRA and member outcomes data to support programs, services, and performance improvement • Investigate potential quality-of-care issues affecting member health or safety • Review medical records and documentation to ensure quality care • Participate in case management and quality committees • Review and update resources, policies, and procedures for member needs and delegated processes • Assist with quarterly reporting and accreditation documentation

🎯 Requirements

• Current Registered Nurse license issued by the state in which services will be provided, or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) • Three years of healthcare clinical experience • Working knowledge of InterQual and/or Milliman Care Guidelines • Knowledge of federal and state laws, NCQA, and industry regulations related to disease management, utilization management, care management, and discharge planning • Excellent written and oral communication • Problem-solving capabilities to improve efficiencies and customer satisfaction • Attention to detail • Proficiency with Microsoft Office • Bachelor's Degree in Nursing or Associate of Science in Nursing Degree (ASN) is preferred • Currently enrolled in a BSN program with BSN completion within three years of hire is preferred • Experience managing Medicare and/or Medicaid populations is preferred • Two years of Care Management experience is preferred